Health Information Management

Communicate with physicians to query effectively

JustCoding News: Inpatient, May 12, 2010

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On April 29, the American Health Information Management Association (AHIMA) issued a practice brief, “Guidance for Clinical Documentation Improvement (CDI) Programs,” which addresses various aspects of the physician query process.

As evidenced by this recent release, coders need to be able to compose an effective query to avoid miscoding for services, which can lead to denials by auditors or other compliance problems.

During the March 24, 2010 HCPro, Inc., audio conference “Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification,” Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, likened a patient’s medical record to a storybook

“Does it read as somebody else could pick up the chart and know exactly what is going on with the patient?” she asked. If the story doesn’t read coherently, don’t hesitate to write another chapter into the patient’s story; a query.

Lynne Spryszak, RN, CCDS, CPC-A, who also spoke during the audio conference, detailed some basic principles for formulating queries. Start by addressing the physician you are querying by name, she said. Don’t leave room for ambiguity by writing, “Dear Doctor.” In addition, always include your own name and contact info.

And remember to always mind your P’s and Q’s. (But just in case you tend to forget here’s a simple mnemonic for the abbreviation “PQ”: Physician Queries = Please and Thank Yous.)

Build policies for compliant queries

One of the first items auditors may look for is a policy regarding queries. Don’t be caught off guard, said Brown.

Establishing query policies within your organization will help set guidelines on who, when, what, and why to query. If you don’t currently have a policy, Brown suggested starting small. For example, start with a single payer, such as Medicare, and then expand once you have mastered a work flow and processes, said Brown. She suggested beginning with Medicare because it has established guidelines that seem easier to measure. The end goal should be to cover all patients.

Ensure your policies and procedures are realistic, said Brown.

Keep queries compliant

Queries must be supported by clinical findings and include a rationale for your inquiry. Use polite, nonconfrontational language when asking for help. At all costs, “avoid sounding as though you’re adding any interpretation” or inclining a specific diagnosis, Brown said.

Avoid asking yes or no questions that could possibly suggest or lean towards a specific diagnosis. Brown noted an exception, however, that yes or no questions are acceptable when asking if a patient’s ailment was present on admission. Otherwise, ask open-ended questions when seeking diagnosis or etiology when possible. If your query becomes too cluttered, offer multiple-choice answers to the physician with rationale for your possible answers, Brown added.

When auditors review queries they look to see if the query was placed at an appropriate time, so you always want to make sure to date and time your query listed clearly, Spryszak said.

And remember, that while physicians are notorious for their poor penmanship, coders shouldn’t fall into that same stereotype when generating queries. If a query is illegible, it won’t matter if it is compliant with your hospital’s or auditor’s policies and it will just add yet another more step of returning and rewriting the query.

Know how and when to query

Balance the value of collecting additional data against the administrative burden of obtaining additional documentation, Spryszak said. If a physician’s documentation contains discrepancies, unaddressed issues, or irrelevant findings, go ahead and query. Coders will develop a better sense of when to query by monitoring the usage of their query forms, Brown said. A high negative response rate may indicate overuse of the query or poor direction on a coder’s part. A high response rate does not always signify complete reporting. On the contrary, “a high response rate may indicate a pattern of incomplete documentation that needs further investigation,” Brown added.

An almost sure-fire way to obtain accuracy and a high response rate is through verbal queries, which, Spryszak contended, are better than written ones “100% of the time.”

“It’s much easier to have a two-way conversation than it is to try to condense everything you want to know on to one short, summarized piece of paper,” she said.

If a physician neglects a written query, find an open time to speak with him or her, preferably before the patient is discharged, Spryszak continued. This way, the case will be fresh in the physician’s mind.

Remember to implement verbal query policies along the same lines of your written ones. Although, you may receive a direct answer during conversation, you must document the meeting, topic, and outcome appropriately.

Deal with dilemma

Ignorance is not bliss in the world of querying, although some physicians might feel that way. Handle disinterested remarks such as, “Just tell me what to write” or “What difference does it make?” from physicians by reiterating that your job is to ensure a specific medical diagnosis for every condition being monitored, evaluated, and treated and the resources used to supply compliant representation of the patient’s condition., Brown said.

Legally, coders cannot tell a physician what to document because they are not licensed treating physicians, said Brown. So stress the importance of documenting the condition that most accurately describes the patient’s ailment and the treatment rendered.

Formalize a follow-up process for those times when a physician ignores or forgets to respond to a query, said Brown. The phrase “documentation is key” may be overused in the healthcare world, but it’s repeated for good reason. Brown suggested formalizing a follow-up system based on the following criteria:

  • Time frames (i.e., how long it takes physician to respond)
  • The number of queries you write
  • Query format
  • The number of “no” responses and disagreements

Try your best to obtain a clear, compliant response, but when all else fails a referral to your boss to help communicate the urgency of the query in question may be in order before reporting a neglectful physician to the department chair or chief of staff. A nonresponse can result in some pretty steep violations for a physician including loss of credentials and contracting processes, said Brown. But, before that step, make certain that your queries are error-proof, the physician had a reasonable amount of time to respond, and you attempted to reach out to the physician in person.

In addition, review those queries for which you’ve had trouble getting a response, said Brown. Look for any patterns of the format of the query, including how coders posed the question. If the query is unclear in any way, the physician may not understand the question, resulting in a non-answer.

Avoid unapproved acronyms

Don’t be tripped up by terms or unapproved abbreviations with multiple meanings, instructed Brown. For example, if a physician writes “RF,” coders may not know whether the physician means renal failure or respiratory failure.

Posing queries using a multiple choice check box format so there is no room for illegible mishaps can help avoid this problem, but remember to leave the option open for a physician to write the appropriate answer in case all of your options are incorrect. For example, you could include an option that says, “Please verify the definition of this abbreviation, or redocument the condition by writing it out in case any of the above options are incorrect. Thank you.”

Spryszak suggested prominently posting the following reminders for coders:

  • Don’t jeopardize putting your facility at risk by not asking the right questions.
  • Think about accuracy.
  • Is it necessary to ask the question?
  • Be compliant by following established, published guidelines.
  • Work together with documentation reviewers and your coding department.
  • Everything you do is based on clinical evidence in the record.
  • Make sure the patient’s story is complete.

Editors note: Please visit the Healthcare Marketplace to learn more about the audio conference “Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification.”

Contact Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, co-author of the Physician Queries Handbook: Guide to Compliant and Effective Communication with further questions at Contact Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro, at

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